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BACKGROUND: Libya had one of the world's largest nosocomial HIV outbreaks in the late 1990s leading to the detention of six foreign medical workers. They were released in 2007 after the Libyan Government and the European Union agreed to humanitarian cooperation that included the development of Libya's first National HIV-Strategy and the research reported in this paper. Despite the absence of sound evidence on the status and dynamics of Libya's HIV-epidemic, some officials posited that injecting drug use (IDU) was a main mode of transmission. We therefore sought to assess HIV-prevalence and related risk factors among people who inject drugs (PWID) in Tripoli. METHODS: We conducted a cross-sectional survey among 328 PWID in Tripoli using respondent-driven sampling. We collected behavioural data and blood samples for HIV, hepatitis C virus (HCV) and hepatitis B virus (HBC) testing. RESULTS: We estimate an HIV-prevalence of 87%, HCV-prevalence of 94% and HBV-prevalence of 5%. We detected IDU-related, and sexual risk factors in the context of poor access to comprehensive services for HIV-prevention and mitigation. For example, most respondents (85%) reported having shared needles. CONCLUSION: In this first bio-behavioural survey among PWID in Libya we detected one of the highest (or even the highest) levels of HIV infection worldwide in the absence of a comprehensive harm-reduction programme. There is urgent need to implement an effective National HIV-Strategy informed by the results of this research, especially because recent military events, and related socio-political disruption and migration might lead to a further expansion of the epidemic.

Objective To assess hospital-level variability in diagnostic testing and outcomes for children with neurologic impairment hospitalized with pneumonia. Study design A retrospective cohort study of 27 455 children ages 1-18 years with neurologic impairment hospitalized with pneumonia at 39 children's hospitals. K-means clustering was used to assign each hospital to 1 of 3 groups (termed A, B, and C) based on similar diagnostic testing patterns. Outcomes of hospital-level median length of stay (LOS), 30-day readmissions, and pneumonia-associated complications were compared while controlling for patient differences. Results Overall, 48.5% had comorbid complex chronic conditions, and 25.4% were assisted with medical technology. Outcomes and diagnostic testing varied across hospitals: median hospital-level LOS, 3.2 days (IQR 2.8-3.8); median readmission, 8.4% (IQR 6.8,-10.0); and median pneumonia-associated complication rate, 23.1% (IQR 18.7-26.8). Despite similar populations, hospitals in group A tended to perform fewer tests than those in groups B and C. Across hospital groups, there was a significant difference in adjusted readmission rates (group A 7.2%, group B 9.0%, group C 7.7%, P = .003). There was no significant difference in adjusted median LOS (group A 3.4 days, group B 3.2 days, group C 3.3 days, P = .3) or adjusted pneumonia-associated complication rates (group A 22.5%, group B 22.5%, group C 25.0%, P = .6). Conclusions For children with neurologic impairment hospitalized with pneumonia, across hospital differences in diagnostic testing were not associated with clinically meaningful differences in outcomes. High-utilizing hospitals may be able to decrease diagnostic testing for children with neurologic impairment hospitalized with pneumonia without adversely impacting outcomes.

Objective To describe hardships experienced by families of children with medical complexity (CMC) and compare them with those experienced by families of children with asthma. Study design We assessed hardships in a cohort of 167 families of CMC. Surveys assessed sociodemographics and hardships (eg, financial: inability to pay bills; social: limited help from family/friends). CMC cohort hardships were compared with those of an established cohort of children hospitalized with asthma using multivariable logistic regression. Results CMC had diagnoses in a median of 5 different complex chronic condition categories (most common neurologic/neuromuscular), and the majority (74%) were dependent on technology. Over 80% of families of CMC reported experiencing ≥1 hardship; 68% with financial and 46% with social hardship. Despite higher socioeconomic status than families with asthma, families of CMC often experienced more hardships. For example, families of CMC were significantly more likely to report failure to pay rent/mortgage (aOR 2.6, 95% CI 1.6, 4.3) and the expectation of little to no help from family/friends (aOR 2.9, 95% CI 1.9, 4.7). Conclusions Families of CMC frequently report financial and social hardships, often at rates higher than families with asthma who were generally of lower socioeconomic status. Identifying and acting upon hardships may be an important addition to the care of CMC.

Background In December 2008, the Institute of Medicine (IOM) released the report of a consensus committee recommending added limits on resident duty hours. Methods Perceptions of interns participating in a 1-month trial implementation of the IOM-recommended duty hour limits in one large pediatric residency program during March 2009 were aggregated. Results Interns experienced benefits from the shift-based schedule, including reduced hours and more nights at home. These were accompanied by shortcomings of the new schedule, most prominently increased intensity during the hours worked, weaknesses in sign-outs and handing off of tasks, and inability to know and “own” all patients on the interns' team. The experiment also changed the role and the level of engagement expected from attending physicians. Conclusions The trial implementation of the IOM-recommended limits highlighted that to adapt to additional reduction in hours, residency education needs a significant culture change, including better sign-outs, improved organization of bedside and didactic education, and attention to the added work intensity of a team-based model with daily admissions. Ultimately this may require an adjustment in residents' workload and different expectations and models of support from attending physicians.

Background There has been no sound evidence on the status and dynamics of Libya’s HIV-epidemic, which is urgently needed to inform near-term policy making while the window of opportunity to act is still open. With funding from the European Union we therefore aimed to assess HIV prevalence and related risk factors among populations most vulnerable to HIV. Methods Using respondent-driven sampling, we conducted a cross-sectional survey among 328 people who inject drugs (PWID), 227 men having sex with men (MSM), and 69 female sex workers (FSW) in Tripoli. We collected behavioural data and blood samples for HIV, hepatitis C and B testing. Results We estimated HIV-prevalence of 87% among PWID, 3% among MSM, and 16% among FSW. We detected high levels of IDU-related, and sexual risk factors, in the context of strong stigma and lack of prevention programmes. Of particular concern, 85% of PWID reported having shared needles, only 21% of MSM used a condom at last sex, and 28% of FSW experienced STI symptoms during the last year. Over a third of MSM had risky sex with men and women and nearly a third of FSW had 50 or more sexual partners in the past six months. Conclusion In this first bio-behavioural survey in Libya we detected among PWID one of the highest (or even the highest) levels of HIV-infection worldwide in the absence of a comprehensive harm-reduction programme. There is urgent need to implement an effective National HIV-Strategy informed by the results of this research, and designed to account for the overlap of high-risk sexual and drug-using networks. The risk of further transmission within different risk groups and to the general population is particularly high given the recent military events that led to increased violence, migration, and the disruption of essential HIV-related services and structures.

Background\ud \ud Publications on Libya’s HIV epidemic mostly examined the victims of the tragic nosocomial HIV outbreak in the 1990s and the related dispute about the detention of foreign medical workers. The dispute resolution in 2003 included an agreement with the European Union on humanitarian cooperation and the development of Libya’s first National HIV Strategy. As part of this we conducted Libya’s first bio-behavioural survey among men having sex with men (MSM) and female sex workers (FSW).\ud \ud Methods\ud \ud Using respondent-driven sampling, we conducted a cross-sectional study to estimate the prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and related risk factors among 227 MSM and 69 FSW in Tripoli (FSW recruitment ended prematurely due to the political events in 2011).\ud \ud Results\ud \ud For MSM we estimated an HIV prevalence of 3.1%, HBV prevalence of 2.9%, and HCV prevalence of 7.3%, and for FSW an HIV prevalence of 15.7%, HBV prevalence of 0%, and HCV prevalence of 5.2%. We detected high levels of risk behaviours, poor HIV-related knowledge, high stigma and lack of prevention programmes. These results must be interpreted in the context of the political situation which prohibited reaching an ideal sample size for FSW.\ud \ud Conclusion\ud \ud There is urgent need to implement an effective National HIV Strategy informed by the results of this research. The risk of transmission within different risk groups and to the general population may be high given the recent military events that led to increased violence, migration, and the disruption of essential HIV-related services.